Not only are hospital readmissions a costly problem for patients and for
the health care system, with studies showing nearly 20 percent of Medicare
patients are readmitted to the hospital at an annual cost of $17 billion, but
they also pose a significant opportunity for improved patient care and safety. They
also represent a complex, multi-faceted issue that still needs to be better
understood. In
new findings from Brigham and
Women's Hospital (BWH), researchers find that the most frequent reasons for
readmission were often related, either directly or indirectly, to patients' underlying
chronic medical conditions (comorbidities), providing a new opportunity for
focus in reducing readmission rates.
This research
is published online in the British Medical Journal on December 16, 2013
and will appear in the January print edition.

"We know that the reason for readmission is
often different from the reason that the patient was initially hospitalized.
Our research shows that the five most frequent reasons for readmission were
often related to patients' existing chronic medical conditions, underscoring
the need for post-discharge care to focus attention not just on the primary
diagnosis of the previous hospitalization but also on these comorbidities,"
said Jacques Donzé, MD, MSc, a research
associate in the Division
of General Internal Medicine at BWH and lead author of the new research.

Researchers evaluated the primary
diagnoses and patterns of 30-day readmissions and potentially avoidable
readmissions according to seven most common comorbidities in medical patients
(chronic heart failure, ischemic heart disease, atrial fibrillation, diabetes
mellitus, cancer, chronic obstructive pulmonary disease, and chronic kidney
disease). They analyzed data from 10,731 discharges, of which, 2,398 or 22
percent, were followed by a 30-day readmission at three hospitals within the
same hospital network. Among the
readmissions, 858, or 8 percent, were categorized as potentially avoidable.

Among the potentially avoidable
readmissions, the overall three most common reasons for readmission were
infection, cancer and heart failure. Heart failure and infection were the two
most frequent main readmission diagnosis for the seven chronic medical
conditions studied, accounting for 21 to 34 percent of all potentially
avoidable readmissions. Interestingly,
almost all of the top five diagnoses of potentially avoidable readmissions for
each comorbidity were possible direct or indirect complications of that
comorbidity. For example, patients discharged with a comorbidity of cancer were
most frequently readmitted for care of their cancer or possibly related
complications like infection, metabolic disorder, gastro-intestinal disorder,
or renal failure. Heart failure was the
most frequent main readmission diagnosis for patients with five of the seven
chronic medical conditions studied.

Particularly important, researchers note
that patients with cancer, heart failure, and chronic kidney disease had a
significantly higher risk of potentially avoidable readmission than those
without those comorbidities.

"Transitions of care should not
only focus on the acute condition responsible for the hospitalization, but also
on patients' underlying chronic conditions that may increase the risk of new,
acute complications," said Donzé. "Our research suggests that interventions
could include close follow-up and monitoring of patients' comorbidities in the
post-discharge period, when we know that patients are particularly vulnerable."

This research was funded by the
Swiss National Science Foundation and the Swiss Foundation for
Medical-Biological Scholarships. The Swiss Science National Foundation and the Swiss Foundation
for Medical-Biological Scholarships had no role in the design and conduct of this
study, the analysis or interpretation of the data, or the preparation of the
manuscript.